Why “Free Birth Control” is Not Free

Many reporters and columnists have consistently used the word "free" when describing the new preventive health care benefits for women under the Affordable Care Act. While these benefits are critical to women's health, public health, and the economic health of our country, they are not "free." (Paid stamp on invoice via Shutterstock)

Yesterday, August 1, 2012, was a momentous day for women, marking the official beginning of a process of ensuring that millions of women across the United States will–finally–have access to a full range of preventive health care services without a co-pay.

These include a wide range of services and interventions identified by the Institutes of Medicine as essential to women’s health and well-being, including breastfeeding support, supplies, and counseling; screening and counseling for interpersonal and domestic violence; screening for gestational diabetes; DNA testing for high-risk strains of HPV; counseling regarding sexually transmitted infections, including HIV; screening for HIV; contraceptive methods and counseling; and well-woman visits. Likewise, the ACA also ensures that plans must cover an array of services, vaccinations, and interventions, including those specifically needed by women, infants, children, and adolescents at different points in their lifecycle.

Unquestionably, due to the efforts of religious and political fundamentalists at the state and federal level to deny women access to reproductive health care of virtually every kind, the benefit that has gotten the most media attention is the one involving contraception without a co-pay. Many media outlets (see ABC, NBC, Grist, Shape.com) and some columnists, including our colleague Amanda Marcotte, have described the new birth control benefit as making contraception “free,” most frequently, for example, stating that now women will have access to birth control for free.

This is not the case, and it is misleading–and politically dangerous–to say so.

To get birth control without a co-pay means you have an insurance policy. No one can walk into any pharmacy today and get the pill without a prescription, which in any case first entails a visit to a doctor’s office. No one without insurance can walk into a doctor’s office and get an IUD for for free, nor any kind of contraception, unless they pay out of pocket or meet the means test for and are covered by Medicaid, an increasingly difficult enterprise in itself but the subject of a different article. Ten percent of women in the United States who work full time are currently uninsured and without coverage, they do not have access to “free” birth control. Nor do other women without insurance, or those whose plans are, for logistical reasons or because they were grand-fathered, not yet compliant with the ACA on preventive care. None of these women have “free” birth control now, and they will not later even if they get insurance. (See the National Women’s Law Center Guide on what to do if you have questions about your insurance plan and contraception without co-pay.)

Why? Because if you have insurance, you pay for it, either by virtue of your labor or out of your own pocket, or, depending on the situation, both. And under the ACA, it is now mandated that your insurance plan cover certain benefits without a co-pay. This does not make them “free.” It means that you are paying for that service as part of your premium. You earned it, you paid for it, it is yours. If you pay for it, you deserve to get it.

My first “real job” after college came with health insurance benefits. I worked very hard in that job, and by extension for those benefits. I earned them through my work in the very same way I earned a matching benefit for my retirement account, the vacation time I got, my life and disability insurance, and the Social Security earnings paid to the government. None of these were a gift. I earned them.

Throughout my career, I have been employed in positions where my health insurance was either fully or partially covered by my employer; in the latter case, the employer share was part of my compensation package (and when I was hired, this was explicitly made clear) and I paid a portion of the insurance premium out of my salary. I was fortunate during much of that time in that I also earned generous health benefits for my children. More recently, I was self-employed for three years, and I paid my insurance premiums in full, out of my pocket, at considerable cost. And I earned every single penny I spent on health insurance and therefore every benefit I got from it.

Under the terms of various of my prior health policies, various medical services, such as well-baby and well-child exams, were covered without a co-pay and did not require me to meet a deductible. Other things, such as our endless visits for my kids’ ear infections, laboratory work, dental care, medical tests, and some doctors visits required co-pays, generally in the range of $15.00 to $50.00 a visit for the simple kinds, and more for the more complicated kinds. I was also often required me to meet a deductible before I could be reimbursed for certain other costs. Prescriptions for me and my kids have invariably cost from $5.00 to $50.00 in co-pays, which, though seemingly small amounts, really begin to add up, especially if you have kids or illness or both.

But those well-baby exams were not “free.” I paid for them with my premium. My insurance premium–paid for and earned by me, and pooled with hundreds of thousands or millions of other people–paid to cover those services. This is a basic principle of health economics and comes down to the old adage, “an ounce of prevention is worth a pound of cure.” Insurance companies don’t make huge profits for nothing. They know that offering certain kinds of preventive care and making that care more accessible to more people means that a small investment in the short-term will keep costs lower in the long term. An early abnormal pap smear leading to early treatment is a lot less expensive for them than is treatment for cervical cancer later on (and quite obviously better for the woman in question). An unwanted pregnancy averted through use of contraception is less expensive than an abortion. And so on.

What the Affordable Care Act does is help to begin making our insurance poilcies and premiums more equitable. As Jessica Arons points out in a comprehensive article, fewer working women than working men in this country have employer-based insurance; insurers have historically charged women more than men in a practice known as gender-rating; and for a very long time, women have paid more out-of-pocket for basic preventive health care services like pap smears and birth control.

The goals of the women’s health provisions in the Affordable Care Act were to begin addressing these disparities, by making women’s access to health care more equitable, and by dramatically reducing the higher costs women pay just because they are women. These changes unquestionably benefit women. But let’s face it, while these are all great things, the reason that lawmakers and insurance companies did this has to do largely with the cost-savings that will be realized: healthier women mean a healthier society and reduced economic and social costs.

Claiming that the services for which women are covered by virtue of their labor and their earnings are “free” feeds into a narrative persistently cultivated by the far right that taxpayers and the government are footing the bill to expand services “for free” to people who did not earn these. It simply is not true.

I fully support expanding government-funded programs to ensure that all women–those living in poverty, low-income women, and the working poor–have access to birth control and other preventive health services, because it makes sense in terms of public health and the economy, and because such access is a basic human right. But people who earn their insurance coverage pay for it, and they deserve the benefit for which they are paying. Moreover, even those who are eligible for government-subsidized access to care–whether reproductive health care or other kinds of care–also are paying at least a share of those costs through their tax contributions. No one is really getting anything here “for free.”

It is notable that the Obama Administration, which has been widely criticized for not doing enough to advertise or explain the many benefits in the Affordable Care Act, does not refer to the birth control benefit as “free contraception.”

Let’s call the birth control benefit what it is: Women’s hard-earned insurance coverage.